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Changes in physical symptoms, blood pressure and quality of life over 30 days
Brla~. Res. T/W-. Vol. 32. No. 6, pp. 593-603. I994 Copyright I(’ 1994 Elsevier ScienceLtd Printed in Great Britain. All rights reserved 0005.7967/94 $7.00 + 0.00
Pergamon
CHANGES
ACHIM
TN PHYSICAL SYMPTOMS, BLOOD PRESSURE AND QUALITY OF LIFE OVER 30 DAYS
MOLLER,’
PEDRO
MONTOYA,
2* RAINER
SCHANDRY,’
and LYDIA HARTL’
‘Institute of Psychology. University of Munich, Leopoldstr. 13, 80802 Munich. Germany ‘Institute of Medical Psychology, University of Tiibingen, Gartenstr. 29, 72074 Tubingen, Germany ‘Max-Planck-Institute of Psychiatry, Munich. Germany (Receired 2 June 1993; receked .for publication 27 August 1993) Summary-The existence of subjective symptoms arising from high blood pressure (BP) remains controversial. Few studies have been performed which compare symptoms of hypertensives and normotensives. The results of these studies are inconsistent. The present study investigates the intensities and prevalences of symptoms of hypertensives and normotensives and the relationship between symptoms and BP for both groups. During a 30-day period, 45 patients with primary hypertension and 45 normotensive controls documented BPS and intensities of 13 symptoms daily as well as mood and life satisfaction weekly. Starting on day 3 hypertensives received beta-blocker therapy (bopindolol. 1mg/day). The BP values of the hypertensives normalized during the study, while the BPS of the normotensives did not change. At the beginning, hypertensives showed higher prevalences and intensities of the symptoms and poorer mood and life satisfaction. After normalization of BP, hypertensives attained scores similar to those of normotensives in all measured categories. Calculating within-S correlations between symptom intensities and systolic BPS, 70% of the hypertensives, but only 27% of the normotensives. showed at least one significant correlation. The differences observed between untreated hypertensives and the normotensive control group with respect to the prevalence and intensity of symptoms provide convincing evidence that untreated hypertensives are by no means symptom-free. The within-S correlations of the present study documented well the close relationship between symptoms and actual BP for a percentage of hypertensives.
INTRODUCTION
In 1913, Janeway (1913) described symptoms of arterial hypertension such as ‘dyspnea’, ‘palpitations’ and ‘headaches’; nevertheless, the existence of subjective symptoms arising from blood pressure (BP) remains questionable to this day. In fact, Hollenberg (1987) recently claimed that “there are no symptoms directly related to hypertension”. Several studies, however, have reported differing prevalence rates fro specific symptoms between hypertensives and normotensives (e.g. Bulpit, Dollery & Carne, 1976; Chatellier, Degoulet, Devriese, Vu, Plouin & Menard, 1982; Dimenas, Wiklund, Dahlof, Lindvall, Olofsson & De Faire, 1989). The results of these studies provide evidence that, as a rule, untreated hypertonics experience considerably more symptoms than normotonics. The question as to whether a causal relationship exists between these symptoms and hypertension was not addressed by these studies. A promising approach to this problem would be to study changes in symptoms during the introduction of antihypertensive therapy. If untreated hypertensives report certain symptoms more frequently than a comparable random sample of normotensives, and if antihypertensive therapy results in a reduction in frequency of these symptoms to a level similar to symptom frequency among normotensives, this could be an indication that the symptom was related to hypertension. Moreover, establishing a significant correlation between the subjectively experienced intensity of a symptom and BP values would provide evidence that this symptom is related to hypertension. Quality of life in addition to physical symptoms has recently been the subject of a number of studies. Several studies could show differences between patient groups under different therapy protocols (Croog, Levine, Testa & Brown, 1986; Welzel & Brautigam, 1988). As such, it may be
*Author
to whom
reprint
requests
should
be addressed. 593
ACHIM MILLER c~f01.
594
concluded that changes in mood or life satisfaction are the result of therapy. There is also a question as to whether observed changes in quality of life are due to a psychotropic effect of the medication per se, or rather the result of lowered BP and, consequently, a reduction in the quantity and intensity of the accompanying symptoms. A simultaneous evaluation of BP changes, symptom intensity and indicators of quality of life should give insight into the interactions between these areas. In the present study, we compared a group of newly diagnosed hypertensives receiving initial treatment with beta-blockers with a group of normotensives over a period of 30 days; we posed the following questions: 1. What differences exist between untreated hypertensive patients and normotensive Ss with respect to the quantity and intensity of the number of reported symptoms? 2. What differences in symptomatology do hypertensives and normotensives exhibit after BP in patients is normalized? 3. What relationship exists between BP values and subjective symptoms over the course of 30 days among (a) normotensives and (b) hypertensives during antihypertensive therapy? 4. What changes in mood and life satisfaction can be observed in the two groups during the course of the study
METHODS Subjects Normotensiaes. Forty-five volunteers (25 females, 20 males) with normal BP and no history of cardiovascular disease constituted the group of normotensives. The mean age was 44.7 years (SD = 15.4; minimum 24; maximum 81). Volunteers received financial compensation (100 German marks). Hypertenskes. A sample was drawn from a group of patients (n = 1017) newly diagnosed as having primary hypertension but no other significant medical problems [results of the complete group have already been reported in Schandry & Freytag (1990)]. These Ss were required to have a pretherapeutic systolic BP of > 160mmHg during the course of antihypertensive therapy. Diastolic values required before therapy were > 95 mmHg and, by the end of the study, < 90 mmHg. Based on the number of normotensive Ss, 45 hypertensive patients were randomly selected from this subgroup (24 males and 21 females; mean age 50.9 years; SD = I I .4; minimum 28; maximum 78). Patients did not receive financial compensation for their participation. Procedure All Ss received a diary and a digital sphygmomanometer (RR-Test Digital Compact, manufacturer Roland Co.). All were instructed in the use of the sphygmomanometer and were requested to record their pulse rate and their systolic and diastolic BPS morning and evening, recording the date and time of the measurements as well. It was requested that participants make these measurements at approximately the same time each day. after sitting quietly for at least 3 min. Each evening, participants reported on a scale of l-6(0 = not at all; I = barely; 2 = mildly; 3 = somewhat; 4 = considerably; 5 = strongly; 6 = very strongly) the degree to which they felt each of 13 specific symptoms at that particular moment. The following list of symptoms was drawn from our previous work (Schandry & Leopold, 1991) and the available literature (e.g. Bulpitt et rr1.,1976; Chatellier et al., 1982; Pennebaker, 1982; Van Reek, Diederiks, Philipsen, Van Zutphen & Seelen. 1982): -Shortness of breath -Cold hands or feet -Throbbing temples -Restlessness --Chest tightness -Headache -Tiredness
-Pounding heart -Clammy hands or feet ---Warmth -Dizziness -Sleep disturbances -Nausea
Symptoms and quality
of life over 30 days
595
On days 2,9, 16, 23 and 30 of the study, participants filled out the German version of the Profile of Mood States (McNair, Lorr & Doppleman, 1971). This questionnaire consists of 35 scaled items; in contrast to the Engsh version of the test, it measures only 4 mood states: ill-humour, vigor, tiredness and depression. On the same day, participants assessed general life satisfaction by means of a 17-item questionnaire, designed to gain information pertaining to their mental, physical and socioeconomic status. Items in this test were scaled in 5 gradations. The questionnaire was a modification of the scale created by Fahrenberg and colleagues (Fahrenberg, Myrtek, Wilk & Kreutel, 1986). Beginning on day 3, and continuing beyond the end of the study, all hypertensives were treated with the beta-blocker bopindolol (1 mg/day); all patients received identical dosages.
RESULTS Blood pressure
(BP)
Among hypertensives, a gradual decline in systolic and diastolic BP over the course of the study was evident. Systolic values decreased, on average, from 174 to 134 mmHg, while diastolic values decreased from 99 to 80mmHg between the first and last day of the study. Among the normotensive volunteers, fluctuations in BP over the course of the study were negligible; systolic pressures averaged 120-125 mmHg, and diastolic pressures averaged 78-83 mmHg (see Fig. 1). A comparison of first-day and last-day mean BP among the hypertensives (r-test for dependent samples) revealed highly significant reductions in BP for systolic (t = 22.2, P < 0.01) as well as diastolic (f = 10.0, P < 0.01) values. Among normotensives, no significant difference in BP between the beginning and the conclusion of the study could be detected. In comparing the mean BP of patients and volunteers (r-test for independent samples), a significant difference was seen at the beginning between the two groups for both systolic (f = 17.1, P < 0.01) and diastolic (t = -8.2, P < 0.01) blood pressures. However, on day 30 a significant difference was only found for systolic values (t = -3.8, P ~0.01). Symptom
prevalence
and intensity
In addressing the question as to how hypertensives differ from normotensives before and after therapy with respect to the symptoms experienced, we evaluated for frequency of specific subjective symptoms as well as for their mean intensity at the beginning and end of the study. In determining the prevalence of symptoms, only those symptoms were taken into accounted which were given a rating of ‘mildly’ (2) or stronger. Figure 2 illustrates the prevalence rates of all symptoms for hypertensives and normotensives at the beginning (day 2) and end (day 30) of the study. (Day 1 was not included, as there was a possibility that participants were not yet accustomed to using the sphygmomanometer and diary.) Antihypertensive therapy did not begin until day 3; as such, the data derived on day 3 were taken from as yet untreated hypertensives. All hypertensive patients had well-controlled BP by day 30. At the beginning of the study, all symptoms were more frequently reported among hypertensives than normotensives. At the end of the study, after normalization of BP in the hypertensives, symptoms showed a frequency that decreases to a level comparable with the frequency of symptoms as reported by the normotensives. Indeed, for the symptoms ‘restlessness’, ‘headache’ and ‘fatigue’, the frequency of symptoms reported by hypertensives was well below the frequency reported by normotensives at the end of the study. A tendency similar to that seen with prevalence rates was seen with mean symptom intensities when comparing the two groups at the beginning and end of the study (see Fig. 3). At the beginning, all symptoms were scored higher in intensity by untreated hypertensives than by normotensives. In comparing mean scores using the r-test for independent samples, significantly higher symptom intensities (P < 0.01 corrected according to Bonferroni-Holm) were found among hypertensives than among normotensives for the following symptoms: ‘throbbing temples’, ‘restlessness’, ‘chest tightness’, ‘headache’, ‘clammy hands or feet’, warmth’ and ‘sleep disturbances’. By the end of the
ACHIM MUELLERer al.
596
Systolic Blood Pressure --
Normotensives
-+-
Hypertensives
mmHg 200 1 180160-
,..,-
1
3
5
7
Q
11 13
15
17
19
21 23
25
27
25
‘27 29
29
Day
Diastolic Blood Pressure --
Normotansives
-+-
Hyper tensives
mmHg 110r
1
3
5
7
9
11 13
15
17
19
21 23
Day Fig. I. Mean systolic
and diastolic
BP of hypertensives
and normotensives
over a 30-day
period
study period, none of the these symptoms were experienced at significantly higher intensity among the treated hypertensives than among the normotensives. In fact, former hypertensives reported markedly less ‘tiredness’ than normotensives at this time. Appropriately, only the average scores for this symptom show a significant difference between the two groups (t-test for independent samples; t = 3.6, P < 0.01). In the literature, there have frequently been reports of increased symptom prevalence at advanced ages (e.g. Bulpitt, Dollery & Carne, 1974; Hale, Perkins, May, Marks & Stewart, 1986). We therefore correlated the sum of the symptom scores over the duration of the study with the age of the participants. There was no significant correlation between the sum of symptoms and age among the normotensives (I = 0.19; P = 0.23) nor among the hypertensives (r = 0.09; P = 0.59).
Symptoms
and quality
of life over 30 days
Day m
Normotensives
597
2 0
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
0
IO
20
30
40
Prevalence
Day m
Normotensives
50
60
70
80
(%)
30 0
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
0
IO
20
30
Prevalence Fig. 2. Prevalences
Intraindividual
of the 13 symptoms
for hypertensives
40
50
60
(%)
and normotensives
at days 2 and 30
correlation
Assessing correlations based on collective data as opposed to within-S correlations neglects to include idiosyncratic elements, which should be expected considering the results of interoceptive perception research (Pennebaker, 1982). Therefore, the evening BP value was correlated with the intensity of each symptom separately for each S. There was at least 1 such significant correlation (P < 0.01) in 69% of patients in the hypertensive group. Among the 585 correlations (45 participants x 13 symptoms), 195 were significantly positive. Only 3 of the significant correlations were negative. The prevalence of significant correlations for each symptom is illustrated in Fig. 4. Significant correlations were most frequent for the symptoms ‘restlessness’ and ‘pounding heart’ and least frequent for ‘nausea’ and ‘dizziness’. In the normotensive group, only 13 positive and 6 negative significant correlations were found. As such, only 22% of the normotensives demonstrated at least 1 significant correlation.
ACHIM MCLLEK et ~1.
59x
Day
k!$#
Normotensives
2
[
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightnes Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea 3
0,5
13
1 Symptom
Day &%!
2
25
30
Normotenslves
i
Hypertensive-s
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
i
0
0,5
1 Symptom
Fig. 3. Mean
intensities
3
Intensity
of the 13 symptoms
for hypertensives
L5
2
&
lntenstty
and normotensives
at days 2 and 30
Mood
Hypertensives showed for all dimensions of mood, as assessed by the Profile of Mood States, a clear and continuous improvement during the course of the study (see Fig. 5); these improvements comparing day 2 and day 30 are significant (t-test for dependent samples; P < 0.01) for each of the 4 mood states assessed. In contrast, no significant changes were seen among the normotensives. When comparing both groups it can be seen that hypertensives showed poorer mood than normotensives at day 2 in all 4 states. In the depression scale we found a significant difference (t-test for independent samples; t = - 2.9; P < 0.01 corrected according to Bonferroni-Holm). By the end of the study, the mood of the hypertensive group was at least as good as the mood of the normotensives.
Symptoms
m
Shortness Cold
and quality
of life over 30 days
Normotenstves
n
of Breath
599
Hypertensives
1
Hands/Feet
Throbbing
Temples
Restlessness Chest
Tightness Headache Tiredness
Pounding Clammy
Heart
I
Hands/Feet Warmth Dizziness
Sleep
Disturbances Nausea
Fza
0
I
Number Fig. 4. Frequency
of significant
J
5
10
15
of Significant
correlations between the intensity hypertensives and normotensives.
20
25
Correlations of symptoms
and systolic
BP for
Life satisfaction Among normotensives, ‘life satisfaction’ remains relatively constant in all the dimensions assessed during the entire study (see Table 1). In contrast, the hypertensives show a significant improvement (P > 0.01, corrected according to Bonferroni-Holm) in the categories ‘health’, ‘physical condition’, ‘mental condition’, ‘mood’, ‘appearance’, ‘abilities’, ‘job situation’, ‘leisure time’ and ‘family life’ (see Table 2). In almost all categories, the hypertensive group scored, on average, less than the normotensive group on day 2 of the study (i.e. before commencement of antihypertensive therapy). At the end of the study period (day 30) the scores of the hypertensives who responded to therapy were higher in all categories than the scores of the normotensive group.
DISCUSSION In comparing following main
the hypertensive and the normotensive results were attained:
groups
over a period
of 1 month,
the
Before commencement of therapy, hypertensive patients showed increased prevalence of symptoms as well as increased means of symptom intensities. In examining the correlation between symptom intensity and BP values during the observation period, for approximately 70% of the patients at least one symptom showed a significant positive correlation with BP. Among the normotensive group, this correlation could only be seen among 22%. While the hypertensive group scored relatively poorly in the profile assessing mood at the beginning of the study, these scores showed significant improvement during antihypertensive therapy, and at the end of the study values were not distinguishable from those of the normotensive group. This was also the case for several criteria used in assessing life satisfaction.
ACHIM MULLER et al.
600
DEPRESSION
ILL-HUMOR 25 20.5 20
20-
n
15 10 5 0
2
9
23
16
30
Day
Day 0
EZ4N ormotensives
Hypertensives
&8
I
251
”
v
9
16
23
30
n. 7
2
9
16
/
23
33
30
Day
Day EZZZ4Normotensives
tiypertensives
VIGOR
TIREDNESS 251
2
a
Normotenwes
EZBN
Hypertensives
Fig. 5. Mean
scores of the 4 mood
variables
measured
ormotenslves
n
Hypertenslves
at weekly intervals
To date, the existence of symptoms accompanying hypertension has rarely been studied, and the results of these few studies are inconsistent and contradictory. Robinson (1969) compared untreated hypertensives with a group of normotensives and came to the conclusion that: “little evidence is found for linking any particular symptom with hypertension”. Bulpitt et al. (1976), on the other hand, in a similar study comparing normotensives with untreated hypertensives, found among hypertensives a significantly higher rate of such symptoms as nocturia, dizziness, visual disturbances, headache and depression. Chatellier et al. (1982) studied a group of untreated hypertensives and found headache, palpitations and dizziness among one-third of their Table
I.
Life satisfaction
Table 2. Life sattsfttction
of the normotensives
of the hypertenswes
2
9
Day 16
23
30
1.7 3.1 1.9 2.5 2.2 2.2 2.4 2.8 2.5 2.5 2.9 2.5 2.2 2.1 2.6 2.4 2.8
2.8 3.3 2.8 3.0 2.1 2.6 2.8 2.9 2.6 2.5 2.9 2.1 2.5 3.0 2.9 2.6 3.0
3.1 3.5 3.0 3.2 3.1 2.9 2.9 3.1 3.0 2.1 3.1 2.8 2.9 3.2 2.9 2.1 3.0
3.3 3.5 3.3 3.4 3.2 2.9 3.0 3.1 2.8 2.6 3.1 2.8 3.1 3.2 3.0 2.7 3.2
3.3 3.5 3.2 3.3 3.1 2.9 3.0 3.0 3 I 2.9 3.2 2.8 3.0 3.3 3.1 2.9 3.3
Day FXICX
Health Medical treatment Physical condition Mental condition Mood Appearance Abilities Character Job situation Financial situation Marriage/relationship Sex life Leisure time Family life Social contacts Social support Life in general
2
9
16
23
30
FaCtOr
2.6 2.6 2.3 2.6 2.5 2.4 2.5 2.1 2.4 2.4 3.0 2.6 2.3 3.0 2.8 2.5 2.8
2.6 2.8 2.5 3.0 2.1 2.5 2.6 2.8 2.7 2.4 3.1 2.5 2.6 3.0 2.1 2.1 2.9
2.6 2.7 2.5 3.0 2.7 2.4 2.7 2.9 2.5 2.4 3.1 2.8 2.5 3.1 2.8 2.7 2.8
2.1 2.9 2.5 3.0 2.7 2.6 2.8 2.9 2.7 2.6 2.9 2.6 2.5 3.0 2.8 2.6 2.9
2.8 2.9 2.5 2.9 2.8 2.6 2.9 2.8 2.6 2.5 3.0 2.8 2.4 2.9 2.8 2.7 2.9
Health Medical treatment Physical condition Mental condition Mood Appearance Abilities Character Job situation Financial situation Marriage/relationship Sex life Leisure time Family life Social contacts Social support Life in general
1
Symptoms
and quality
of life over 30 days
601
patients. Van Reek et al. (1982) examined volunteers with BPS ranging from hypotensive to hypertensive and found a linear correlation between diastolic BP and the sum of symptoms noted when diastolic pressures were >95 mmHg. Dimenas et al. (1989) classified their Ss on the basis of diastolic BP into normotensives (diastolic BP < 85 mmHg), borderline hypertensives (diastolic BP = 85595 mmHg) and hypertensives (diastolic BP > 95 mmHg). Borderline hypertensives revealed significantly higher values for gastrointestinal symptoms than did the other two groups. Hypertensives exhibited significantly higher increases in scores for cardiac symptoms than normotensives and borderline hypertensives. This apparent inconsistency between these studies is probably due to differences in the data collection methods as well as in the symptom scales used; major differences were also seen in the inclusion criteria for the hypertensive groups. In the present study, the inclusion criteria for the hypertensive group were defined according to the World Health Organization’s guidelines (diastolic BP > 95 mmHg; systolic BP > 160 mmHg). In addition, BP measurements were made not only at a single point in time, but rather, regularly during the l-month time period following the commencement of antihypertensive therapy, so that the assessment of the correlation between symptom reports and actual BP values had a broader database from which conclusions could be drawn. Therapy was begun on day 3 of the study, making it possible to gather data from cases before as well as during antihypertensive therapy. The differences observed between untreated hypertensives and the normotensive control group with respect to the prevalence and intensity of symptoms provide convincing evidence that untreated hypertensives are by no means symptom-free. These differences were greatest for the symptoms ‘restlessness’, ‘headache’, ‘chest tightness’, ‘throbbing temples’, ‘moist hands and/or feet’ and ‘sleep disturbances’ Other authors have also described these symptoms as being related to hypertension (see above). During the course of therapy all symptoms showed significant decreases and, by the end of the study, treated hypertensives showed symptom prevalence and intensities that did not appreciably differ from those of the normal control group. Within-S correlation is the method of first choice in assessing the potential relationships between the intensity of individual symptoms and measured BP values (Cox, Gonder-Fredrick, Pohl & Pennebaker, 1983; Baumann & Leventhal, 1985; Pennebaker & Watson, 1988). The within-S correlations of the present study document well the relationship between symptoms and actual BP for a high percentage of hypertensives. This result is similar to findings of Pennebaker and Watson (1988) who however found significant correlation between symptom intensity and systolic BP in only 36% of their Ss. The lower correlation seen in Pennebaker and Watson’s (1988) study can be explained by differences in the study design and the sampling process. Their patient group consisted of hypertensives whose BPS were well-controlled at the outset of the experiment, and BP fluctuations were induced artificially under stressful laboratory conditions. We conclude from our results that symptoms exist which do indeed correlate closely with BP values. The existence of a causal relationship between these two variables or the possible existence of a third variable that might be responsible for changes in the symptoms reported can of course not be inferred from a correlative statistical study. Nevertheless, for individual patients it is often the case that typical symptoms, or symptom complexes, consistently appear during periods of raise BP, which might make them aware of changes in their BP. The ability of hypertensive patients to take note of changes in their BP is important for at least two reasons: (a) the conscious experience of alleviation of symptoms as a consequence of antihypertensive medication could have a behavior regulating effect, resulting in improved patient compliance; and (b) situations and forms of behavior that may result in increases in BP can be identified on the basis of the symptoms arising at that time; appropriate actions and reactions can then be decided upon (stress reduction, conflict resolution conflicts etc.). Emotional states play a considerable role in the concept ‘quality of life’. In contrast to other studies (e.g. Kaplan, 1983; Rosen & Kostis, 1985) in which beta-blocker therapy was linked to depressive mood changes, we found the results of such therapy to be largely positive for all 4 of the aspects examined here. The hypertensives in our study exhibited markedly worse scores in assessment of mood at the beginning of the experiment. This may have been the result of having learned of the hypertensive diagnosis from the treating physician 2 days before the initial mood assessment.
602
ACHIM MUELLER et al.
This could have led to a worsening of general mood. At the end of the study period hypertensives showed notably better scores than normotensives on scales assessing ill-humor, tiredness and vigor; these results may have been due to the positive developments seen in their health situations, whereas normotensives experienced neither negative nor positive changes in their health status. It cannot of course be excluded that the medications themselves were responsible for changes in mood (Welzel & Brautigam, 1988; Hallberg, Almgren & Svensson, 1982). Resolving this question would necessitate carefully controlled placebo trials. The improvements seen in the mental condition of hypertensive patients are supported by findings from the contentment scale. In particular, differences are seen for items that refer to health, therapy and physical /mental condition. Notable among the hypertensives is the improvement in satisfaction with their sex lives during the course of the therapy. This result contrasts sharply with the common notion that antihypertensive treatment with beta-blockers often results in sexual impairment and/or reduced sexual satisfaction (Mann, Abbot, Gray, Thiebaux & Belzer, 1982; Williams, 1987). The validity of the life satisfaction data is underscored by the finding that scores on the items ‘satisfaction with character’ or ‘satisfaction with financial situation’ did not show any significant changes during the course of the study; it is the purpose of these items to serve as controls in the life satisfaction scale. On the basis of our data, we conclude that there is a marked difference in the symptom profile between hypertensives and healthy individuals. In our assessment there is justification for claiming symptoms of hypertensives to be insignificant. Moreover, it can be seen that antihypertensive therapy increases the quality of life in patients soon after the commencement of therapy. Of course, this statement is only valid when no significant side effects caused exclusively by medication occur, and when BP reduction occurs in a controlled manner, preventing typical symptoms of hypotension. A(kllollled~ements-The Forschung Munchen
authors gratefully acknowledge GmbH and Mrs Barbara Steinkopf
the support for acquiring
of the Wander the data.
pharmaceutical
firm.
Klinische
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of life. over 30 days
603
Robinson, J. 0. (1969). Symptoms and the discovery of high blood pressure. Journal qf Psychosomatic Research, 13, 157-161. Rosen, R. C. & Kostis, J. B. (1985). Biobehavior sequellae associated with adrenergic-inhibiting antihypertensive agents: a critical review. HPSY, 4, 597404. Schandry, R. & Freytag, S. (1990). Befindiichkeit bei antihypertensiver Therapie. medw/r, 41, 635444. Schandry, R. & Leopold, C. (1991). Zum Zusammenhang z&hen Blutdruck, Symptomreport und psychischem Befineden bei Hypertonikern. In Bullinger, M., Ludwig, M. & von Steinbiichel, N. (Eds) Lehensyualitijr hei kardiot:askultiren Erkra&ngen (pp. 137-152). Gottingen: Hogrefe. Van Reek, J., Diederiks, J., Philipsen, H., Van Zutphen, W. & Seelen, T. (1982). Subjective complaints and blood pressure. Journaf qf P.syrhosomatic Research. 26, 155-I65. Welzel, D. & Br~utigam, M. (1988). Quality of life as a dimension in drug development. Current U~i~~o~~.sin ~izrdj[)~~~~~. 3 giuppi. 2). 5964. Williams, G. H. (1987). Quality of life and its impact on hypertensive patients. American Journal of Medicine, 82. 98-105.
Pergamon
CHANGES
ACHIM
TN PHYSICAL SYMPTOMS, BLOOD PRESSURE AND QUALITY OF LIFE OVER 30 DAYS
MOLLER,’
PEDRO
MONTOYA,
2* RAINER
SCHANDRY,’
and LYDIA HARTL’
‘Institute of Psychology. University of Munich, Leopoldstr. 13, 80802 Munich. Germany ‘Institute of Medical Psychology, University of Tiibingen, Gartenstr. 29, 72074 Tubingen, Germany ‘Max-Planck-Institute of Psychiatry, Munich. Germany (Receired 2 June 1993; receked .for publication 27 August 1993) Summary-The existence of subjective symptoms arising from high blood pressure (BP) remains controversial. Few studies have been performed which compare symptoms of hypertensives and normotensives. The results of these studies are inconsistent. The present study investigates the intensities and prevalences of symptoms of hypertensives and normotensives and the relationship between symptoms and BP for both groups. During a 30-day period, 45 patients with primary hypertension and 45 normotensive controls documented BPS and intensities of 13 symptoms daily as well as mood and life satisfaction weekly. Starting on day 3 hypertensives received beta-blocker therapy (bopindolol. 1mg/day). The BP values of the hypertensives normalized during the study, while the BPS of the normotensives did not change. At the beginning, hypertensives showed higher prevalences and intensities of the symptoms and poorer mood and life satisfaction. After normalization of BP, hypertensives attained scores similar to those of normotensives in all measured categories. Calculating within-S correlations between symptom intensities and systolic BPS, 70% of the hypertensives, but only 27% of the normotensives. showed at least one significant correlation. The differences observed between untreated hypertensives and the normotensive control group with respect to the prevalence and intensity of symptoms provide convincing evidence that untreated hypertensives are by no means symptom-free. The within-S correlations of the present study documented well the close relationship between symptoms and actual BP for a percentage of hypertensives.
INTRODUCTION
In 1913, Janeway (1913) described symptoms of arterial hypertension such as ‘dyspnea’, ‘palpitations’ and ‘headaches’; nevertheless, the existence of subjective symptoms arising from blood pressure (BP) remains questionable to this day. In fact, Hollenberg (1987) recently claimed that “there are no symptoms directly related to hypertension”. Several studies, however, have reported differing prevalence rates fro specific symptoms between hypertensives and normotensives (e.g. Bulpit, Dollery & Carne, 1976; Chatellier, Degoulet, Devriese, Vu, Plouin & Menard, 1982; Dimenas, Wiklund, Dahlof, Lindvall, Olofsson & De Faire, 1989). The results of these studies provide evidence that, as a rule, untreated hypertonics experience considerably more symptoms than normotonics. The question as to whether a causal relationship exists between these symptoms and hypertension was not addressed by these studies. A promising approach to this problem would be to study changes in symptoms during the introduction of antihypertensive therapy. If untreated hypertensives report certain symptoms more frequently than a comparable random sample of normotensives, and if antihypertensive therapy results in a reduction in frequency of these symptoms to a level similar to symptom frequency among normotensives, this could be an indication that the symptom was related to hypertension. Moreover, establishing a significant correlation between the subjectively experienced intensity of a symptom and BP values would provide evidence that this symptom is related to hypertension. Quality of life in addition to physical symptoms has recently been the subject of a number of studies. Several studies could show differences between patient groups under different therapy protocols (Croog, Levine, Testa & Brown, 1986; Welzel & Brautigam, 1988). As such, it may be
*Author
to whom
reprint
requests
should
be addressed. 593
ACHIM MILLER c~f01.
594
concluded that changes in mood or life satisfaction are the result of therapy. There is also a question as to whether observed changes in quality of life are due to a psychotropic effect of the medication per se, or rather the result of lowered BP and, consequently, a reduction in the quantity and intensity of the accompanying symptoms. A simultaneous evaluation of BP changes, symptom intensity and indicators of quality of life should give insight into the interactions between these areas. In the present study, we compared a group of newly diagnosed hypertensives receiving initial treatment with beta-blockers with a group of normotensives over a period of 30 days; we posed the following questions: 1. What differences exist between untreated hypertensive patients and normotensive Ss with respect to the quantity and intensity of the number of reported symptoms? 2. What differences in symptomatology do hypertensives and normotensives exhibit after BP in patients is normalized? 3. What relationship exists between BP values and subjective symptoms over the course of 30 days among (a) normotensives and (b) hypertensives during antihypertensive therapy? 4. What changes in mood and life satisfaction can be observed in the two groups during the course of the study
METHODS Subjects Normotensiaes. Forty-five volunteers (25 females, 20 males) with normal BP and no history of cardiovascular disease constituted the group of normotensives. The mean age was 44.7 years (SD = 15.4; minimum 24; maximum 81). Volunteers received financial compensation (100 German marks). Hypertenskes. A sample was drawn from a group of patients (n = 1017) newly diagnosed as having primary hypertension but no other significant medical problems [results of the complete group have already been reported in Schandry & Freytag (1990)]. These Ss were required to have a pretherapeutic systolic BP of > 160mmHg during the course of antihypertensive therapy. Diastolic values required before therapy were > 95 mmHg and, by the end of the study, < 90 mmHg. Based on the number of normotensive Ss, 45 hypertensive patients were randomly selected from this subgroup (24 males and 21 females; mean age 50.9 years; SD = I I .4; minimum 28; maximum 78). Patients did not receive financial compensation for their participation. Procedure All Ss received a diary and a digital sphygmomanometer (RR-Test Digital Compact, manufacturer Roland Co.). All were instructed in the use of the sphygmomanometer and were requested to record their pulse rate and their systolic and diastolic BPS morning and evening, recording the date and time of the measurements as well. It was requested that participants make these measurements at approximately the same time each day. after sitting quietly for at least 3 min. Each evening, participants reported on a scale of l-6(0 = not at all; I = barely; 2 = mildly; 3 = somewhat; 4 = considerably; 5 = strongly; 6 = very strongly) the degree to which they felt each of 13 specific symptoms at that particular moment. The following list of symptoms was drawn from our previous work (Schandry & Leopold, 1991) and the available literature (e.g. Bulpitt et rr1.,1976; Chatellier et al., 1982; Pennebaker, 1982; Van Reek, Diederiks, Philipsen, Van Zutphen & Seelen. 1982): -Shortness of breath -Cold hands or feet -Throbbing temples -Restlessness --Chest tightness -Headache -Tiredness
-Pounding heart -Clammy hands or feet ---Warmth -Dizziness -Sleep disturbances -Nausea
Symptoms and quality
of life over 30 days
595
On days 2,9, 16, 23 and 30 of the study, participants filled out the German version of the Profile of Mood States (McNair, Lorr & Doppleman, 1971). This questionnaire consists of 35 scaled items; in contrast to the Engsh version of the test, it measures only 4 mood states: ill-humour, vigor, tiredness and depression. On the same day, participants assessed general life satisfaction by means of a 17-item questionnaire, designed to gain information pertaining to their mental, physical and socioeconomic status. Items in this test were scaled in 5 gradations. The questionnaire was a modification of the scale created by Fahrenberg and colleagues (Fahrenberg, Myrtek, Wilk & Kreutel, 1986). Beginning on day 3, and continuing beyond the end of the study, all hypertensives were treated with the beta-blocker bopindolol (1 mg/day); all patients received identical dosages.
RESULTS Blood pressure
(BP)
Among hypertensives, a gradual decline in systolic and diastolic BP over the course of the study was evident. Systolic values decreased, on average, from 174 to 134 mmHg, while diastolic values decreased from 99 to 80mmHg between the first and last day of the study. Among the normotensive volunteers, fluctuations in BP over the course of the study were negligible; systolic pressures averaged 120-125 mmHg, and diastolic pressures averaged 78-83 mmHg (see Fig. 1). A comparison of first-day and last-day mean BP among the hypertensives (r-test for dependent samples) revealed highly significant reductions in BP for systolic (t = 22.2, P < 0.01) as well as diastolic (f = 10.0, P < 0.01) values. Among normotensives, no significant difference in BP between the beginning and the conclusion of the study could be detected. In comparing the mean BP of patients and volunteers (r-test for independent samples), a significant difference was seen at the beginning between the two groups for both systolic (f = 17.1, P < 0.01) and diastolic (t = -8.2, P < 0.01) blood pressures. However, on day 30 a significant difference was only found for systolic values (t = -3.8, P ~0.01). Symptom
prevalence
and intensity
In addressing the question as to how hypertensives differ from normotensives before and after therapy with respect to the symptoms experienced, we evaluated for frequency of specific subjective symptoms as well as for their mean intensity at the beginning and end of the study. In determining the prevalence of symptoms, only those symptoms were taken into accounted which were given a rating of ‘mildly’ (2) or stronger. Figure 2 illustrates the prevalence rates of all symptoms for hypertensives and normotensives at the beginning (day 2) and end (day 30) of the study. (Day 1 was not included, as there was a possibility that participants were not yet accustomed to using the sphygmomanometer and diary.) Antihypertensive therapy did not begin until day 3; as such, the data derived on day 3 were taken from as yet untreated hypertensives. All hypertensive patients had well-controlled BP by day 30. At the beginning of the study, all symptoms were more frequently reported among hypertensives than normotensives. At the end of the study, after normalization of BP in the hypertensives, symptoms showed a frequency that decreases to a level comparable with the frequency of symptoms as reported by the normotensives. Indeed, for the symptoms ‘restlessness’, ‘headache’ and ‘fatigue’, the frequency of symptoms reported by hypertensives was well below the frequency reported by normotensives at the end of the study. A tendency similar to that seen with prevalence rates was seen with mean symptom intensities when comparing the two groups at the beginning and end of the study (see Fig. 3). At the beginning, all symptoms were scored higher in intensity by untreated hypertensives than by normotensives. In comparing mean scores using the r-test for independent samples, significantly higher symptom intensities (P < 0.01 corrected according to Bonferroni-Holm) were found among hypertensives than among normotensives for the following symptoms: ‘throbbing temples’, ‘restlessness’, ‘chest tightness’, ‘headache’, ‘clammy hands or feet’, warmth’ and ‘sleep disturbances’. By the end of the
ACHIM MUELLERer al.
596
Systolic Blood Pressure --
Normotensives
-+-
Hypertensives
mmHg 200 1 180160-
,..,-
1
3
5
7
Q
11 13
15
17
19
21 23
25
27
25
‘27 29
29
Day
Diastolic Blood Pressure --
Normotansives
-+-
Hyper tensives
mmHg 110r
1
3
5
7
9
11 13
15
17
19
21 23
Day Fig. I. Mean systolic
and diastolic
BP of hypertensives
and normotensives
over a 30-day
period
study period, none of the these symptoms were experienced at significantly higher intensity among the treated hypertensives than among the normotensives. In fact, former hypertensives reported markedly less ‘tiredness’ than normotensives at this time. Appropriately, only the average scores for this symptom show a significant difference between the two groups (t-test for independent samples; t = 3.6, P < 0.01). In the literature, there have frequently been reports of increased symptom prevalence at advanced ages (e.g. Bulpitt, Dollery & Carne, 1974; Hale, Perkins, May, Marks & Stewart, 1986). We therefore correlated the sum of the symptom scores over the duration of the study with the age of the participants. There was no significant correlation between the sum of symptoms and age among the normotensives (I = 0.19; P = 0.23) nor among the hypertensives (r = 0.09; P = 0.59).
Symptoms
and quality
of life over 30 days
Day m
Normotensives
597
2 0
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
0
IO
20
30
40
Prevalence
Day m
Normotensives
50
60
70
80
(%)
30 0
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
0
IO
20
30
Prevalence Fig. 2. Prevalences
Intraindividual
of the 13 symptoms
for hypertensives
40
50
60
(%)
and normotensives
at days 2 and 30
correlation
Assessing correlations based on collective data as opposed to within-S correlations neglects to include idiosyncratic elements, which should be expected considering the results of interoceptive perception research (Pennebaker, 1982). Therefore, the evening BP value was correlated with the intensity of each symptom separately for each S. There was at least 1 such significant correlation (P < 0.01) in 69% of patients in the hypertensive group. Among the 585 correlations (45 participants x 13 symptoms), 195 were significantly positive. Only 3 of the significant correlations were negative. The prevalence of significant correlations for each symptom is illustrated in Fig. 4. Significant correlations were most frequent for the symptoms ‘restlessness’ and ‘pounding heart’ and least frequent for ‘nausea’ and ‘dizziness’. In the normotensive group, only 13 positive and 6 negative significant correlations were found. As such, only 22% of the normotensives demonstrated at least 1 significant correlation.
ACHIM MCLLEK et ~1.
59x
Day
k!$#
Normotensives
2
[
Hypertensives
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightnes Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea 3
0,5
13
1 Symptom
Day &%!
2
25
30
Normotenslves
i
Hypertensive-s
Shortness of Breath Cold Hands/Feet Throbbing Temples Restlessness Chest Tightness Headache Tiredness Pounding Heart Clammy Hands/Feet Warmth Dizziness Sleep Disturbances Nausea
i
0
0,5
1 Symptom
Fig. 3. Mean
intensities
3
Intensity
of the 13 symptoms
for hypertensives
L5
2
&
lntenstty
and normotensives
at days 2 and 30
Mood
Hypertensives showed for all dimensions of mood, as assessed by the Profile of Mood States, a clear and continuous improvement during the course of the study (see Fig. 5); these improvements comparing day 2 and day 30 are significant (t-test for dependent samples; P < 0.01) for each of the 4 mood states assessed. In contrast, no significant changes were seen among the normotensives. When comparing both groups it can be seen that hypertensives showed poorer mood than normotensives at day 2 in all 4 states. In the depression scale we found a significant difference (t-test for independent samples; t = - 2.9; P < 0.01 corrected according to Bonferroni-Holm). By the end of the study, the mood of the hypertensive group was at least as good as the mood of the normotensives.
Symptoms
m
Shortness Cold
and quality
of life over 30 days
Normotenstves
n
of Breath
599
Hypertensives
1
Hands/Feet
Throbbing
Temples
Restlessness Chest
Tightness Headache Tiredness
Pounding Clammy
Heart
I
Hands/Feet Warmth Dizziness
Sleep
Disturbances Nausea
Fza
0
I
Number Fig. 4. Frequency
of significant
J
5
10
15
of Significant
correlations between the intensity hypertensives and normotensives.
20
25
Correlations of symptoms
and systolic
BP for
Life satisfaction Among normotensives, ‘life satisfaction’ remains relatively constant in all the dimensions assessed during the entire study (see Table 1). In contrast, the hypertensives show a significant improvement (P > 0.01, corrected according to Bonferroni-Holm) in the categories ‘health’, ‘physical condition’, ‘mental condition’, ‘mood’, ‘appearance’, ‘abilities’, ‘job situation’, ‘leisure time’ and ‘family life’ (see Table 2). In almost all categories, the hypertensive group scored, on average, less than the normotensive group on day 2 of the study (i.e. before commencement of antihypertensive therapy). At the end of the study period (day 30) the scores of the hypertensives who responded to therapy were higher in all categories than the scores of the normotensive group.
DISCUSSION In comparing following main
the hypertensive and the normotensive results were attained:
groups
over a period
of 1 month,
the
Before commencement of therapy, hypertensive patients showed increased prevalence of symptoms as well as increased means of symptom intensities. In examining the correlation between symptom intensity and BP values during the observation period, for approximately 70% of the patients at least one symptom showed a significant positive correlation with BP. Among the normotensive group, this correlation could only be seen among 22%. While the hypertensive group scored relatively poorly in the profile assessing mood at the beginning of the study, these scores showed significant improvement during antihypertensive therapy, and at the end of the study values were not distinguishable from those of the normotensive group. This was also the case for several criteria used in assessing life satisfaction.
ACHIM MULLER et al.
600
DEPRESSION
ILL-HUMOR 25 20.5 20
20-
n
15 10 5 0
2
9
23
16
30
Day
Day 0
EZ4N ormotensives
Hypertensives
&8
I
251
”
v
9
16
23
30
n. 7
2
9
16
/
23
33
30
Day
Day EZZZ4Normotensives
tiypertensives
VIGOR
TIREDNESS 251
2
a
Normotenwes
EZBN
Hypertensives
Fig. 5. Mean
scores of the 4 mood
variables
measured
ormotenslves
n
Hypertenslves
at weekly intervals
To date, the existence of symptoms accompanying hypertension has rarely been studied, and the results of these few studies are inconsistent and contradictory. Robinson (1969) compared untreated hypertensives with a group of normotensives and came to the conclusion that: “little evidence is found for linking any particular symptom with hypertension”. Bulpitt et al. (1976), on the other hand, in a similar study comparing normotensives with untreated hypertensives, found among hypertensives a significantly higher rate of such symptoms as nocturia, dizziness, visual disturbances, headache and depression. Chatellier et al. (1982) studied a group of untreated hypertensives and found headache, palpitations and dizziness among one-third of their Table
I.
Life satisfaction
Table 2. Life sattsfttction
of the normotensives
of the hypertenswes
2
9
Day 16
23
30
1.7 3.1 1.9 2.5 2.2 2.2 2.4 2.8 2.5 2.5 2.9 2.5 2.2 2.1 2.6 2.4 2.8
2.8 3.3 2.8 3.0 2.1 2.6 2.8 2.9 2.6 2.5 2.9 2.1 2.5 3.0 2.9 2.6 3.0
3.1 3.5 3.0 3.2 3.1 2.9 2.9 3.1 3.0 2.1 3.1 2.8 2.9 3.2 2.9 2.1 3.0
3.3 3.5 3.3 3.4 3.2 2.9 3.0 3.1 2.8 2.6 3.1 2.8 3.1 3.2 3.0 2.7 3.2
3.3 3.5 3.2 3.3 3.1 2.9 3.0 3.0 3 I 2.9 3.2 2.8 3.0 3.3 3.1 2.9 3.3
Day FXICX
Health Medical treatment Physical condition Mental condition Mood Appearance Abilities Character Job situation Financial situation Marriage/relationship Sex life Leisure time Family life Social contacts Social support Life in general
2
9
16
23
30
FaCtOr
2.6 2.6 2.3 2.6 2.5 2.4 2.5 2.1 2.4 2.4 3.0 2.6 2.3 3.0 2.8 2.5 2.8
2.6 2.8 2.5 3.0 2.1 2.5 2.6 2.8 2.7 2.4 3.1 2.5 2.6 3.0 2.1 2.1 2.9
2.6 2.7 2.5 3.0 2.7 2.4 2.7 2.9 2.5 2.4 3.1 2.8 2.5 3.1 2.8 2.7 2.8
2.1 2.9 2.5 3.0 2.7 2.6 2.8 2.9 2.7 2.6 2.9 2.6 2.5 3.0 2.8 2.6 2.9
2.8 2.9 2.5 2.9 2.8 2.6 2.9 2.8 2.6 2.5 3.0 2.8 2.4 2.9 2.8 2.7 2.9
Health Medical treatment Physical condition Mental condition Mood Appearance Abilities Character Job situation Financial situation Marriage/relationship Sex life Leisure time Family life Social contacts Social support Life in general
1
Symptoms
and quality
of life over 30 days
601
patients. Van Reek et al. (1982) examined volunteers with BPS ranging from hypotensive to hypertensive and found a linear correlation between diastolic BP and the sum of symptoms noted when diastolic pressures were >95 mmHg. Dimenas et al. (1989) classified their Ss on the basis of diastolic BP into normotensives (diastolic BP < 85 mmHg), borderline hypertensives (diastolic BP = 85595 mmHg) and hypertensives (diastolic BP > 95 mmHg). Borderline hypertensives revealed significantly higher values for gastrointestinal symptoms than did the other two groups. Hypertensives exhibited significantly higher increases in scores for cardiac symptoms than normotensives and borderline hypertensives. This apparent inconsistency between these studies is probably due to differences in the data collection methods as well as in the symptom scales used; major differences were also seen in the inclusion criteria for the hypertensive groups. In the present study, the inclusion criteria for the hypertensive group were defined according to the World Health Organization’s guidelines (diastolic BP > 95 mmHg; systolic BP > 160 mmHg). In addition, BP measurements were made not only at a single point in time, but rather, regularly during the l-month time period following the commencement of antihypertensive therapy, so that the assessment of the correlation between symptom reports and actual BP values had a broader database from which conclusions could be drawn. Therapy was begun on day 3 of the study, making it possible to gather data from cases before as well as during antihypertensive therapy. The differences observed between untreated hypertensives and the normotensive control group with respect to the prevalence and intensity of symptoms provide convincing evidence that untreated hypertensives are by no means symptom-free. These differences were greatest for the symptoms ‘restlessness’, ‘headache’, ‘chest tightness’, ‘throbbing temples’, ‘moist hands and/or feet’ and ‘sleep disturbances’ Other authors have also described these symptoms as being related to hypertension (see above). During the course of therapy all symptoms showed significant decreases and, by the end of the study, treated hypertensives showed symptom prevalence and intensities that did not appreciably differ from those of the normal control group. Within-S correlation is the method of first choice in assessing the potential relationships between the intensity of individual symptoms and measured BP values (Cox, Gonder-Fredrick, Pohl & Pennebaker, 1983; Baumann & Leventhal, 1985; Pennebaker & Watson, 1988). The within-S correlations of the present study document well the relationship between symptoms and actual BP for a high percentage of hypertensives. This result is similar to findings of Pennebaker and Watson (1988) who however found significant correlation between symptom intensity and systolic BP in only 36% of their Ss. The lower correlation seen in Pennebaker and Watson’s (1988) study can be explained by differences in the study design and the sampling process. Their patient group consisted of hypertensives whose BPS were well-controlled at the outset of the experiment, and BP fluctuations were induced artificially under stressful laboratory conditions. We conclude from our results that symptoms exist which do indeed correlate closely with BP values. The existence of a causal relationship between these two variables or the possible existence of a third variable that might be responsible for changes in the symptoms reported can of course not be inferred from a correlative statistical study. Nevertheless, for individual patients it is often the case that typical symptoms, or symptom complexes, consistently appear during periods of raise BP, which might make them aware of changes in their BP. The ability of hypertensive patients to take note of changes in their BP is important for at least two reasons: (a) the conscious experience of alleviation of symptoms as a consequence of antihypertensive medication could have a behavior regulating effect, resulting in improved patient compliance; and (b) situations and forms of behavior that may result in increases in BP can be identified on the basis of the symptoms arising at that time; appropriate actions and reactions can then be decided upon (stress reduction, conflict resolution conflicts etc.). Emotional states play a considerable role in the concept ‘quality of life’. In contrast to other studies (e.g. Kaplan, 1983; Rosen & Kostis, 1985) in which beta-blocker therapy was linked to depressive mood changes, we found the results of such therapy to be largely positive for all 4 of the aspects examined here. The hypertensives in our study exhibited markedly worse scores in assessment of mood at the beginning of the experiment. This may have been the result of having learned of the hypertensive diagnosis from the treating physician 2 days before the initial mood assessment.
602
ACHIM MUELLER et al.
This could have led to a worsening of general mood. At the end of the study period hypertensives showed notably better scores than normotensives on scales assessing ill-humor, tiredness and vigor; these results may have been due to the positive developments seen in their health situations, whereas normotensives experienced neither negative nor positive changes in their health status. It cannot of course be excluded that the medications themselves were responsible for changes in mood (Welzel & Brautigam, 1988; Hallberg, Almgren & Svensson, 1982). Resolving this question would necessitate carefully controlled placebo trials. The improvements seen in the mental condition of hypertensive patients are supported by findings from the contentment scale. In particular, differences are seen for items that refer to health, therapy and physical /mental condition. Notable among the hypertensives is the improvement in satisfaction with their sex lives during the course of the therapy. This result contrasts sharply with the common notion that antihypertensive treatment with beta-blockers often results in sexual impairment and/or reduced sexual satisfaction (Mann, Abbot, Gray, Thiebaux & Belzer, 1982; Williams, 1987). The validity of the life satisfaction data is underscored by the finding that scores on the items ‘satisfaction with character’ or ‘satisfaction with financial situation’ did not show any significant changes during the course of the study; it is the purpose of these items to serve as controls in the life satisfaction scale. On the basis of our data, we conclude that there is a marked difference in the symptom profile between hypertensives and healthy individuals. In our assessment there is justification for claiming symptoms of hypertensives to be insignificant. Moreover, it can be seen that antihypertensive therapy increases the quality of life in patients soon after the commencement of therapy. Of course, this statement is only valid when no significant side effects caused exclusively by medication occur, and when BP reduction occurs in a controlled manner, preventing typical symptoms of hypotension. A(kllollled~ements-The Forschung Munchen
authors gratefully acknowledge GmbH and Mrs Barbara Steinkopf
the support for acquiring
of the Wander the data.
pharmaceutical
firm.
Klinische
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Janeway,
T. C. (1913).
A clinical
study
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cardiovascular
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